Wiki Chief Complaint

[az2tn@yahoo.com]

I new to auditing and I'm being told that the previous auditor allowed the chief complaint to be inferred from the plan. I've never heard this before but I cannot find any guidance that specifically states that it can't. Anyone have any documentation that spells out where the cc can be taken from? Thanks in advance

 

[MnTwins29]

I new to auditing and I'm being told that the previous auditor allowed the chief complaint to be inferred from the plan. I've never heard this before but I cannot find any guidance that specifically states that it can't. Anyone have any documentation that spells out where the cc can be taken from? Thanks in advance

I would refer to the CMS E/M Documentation Guidelines, 1995 or 1997 as they both state the same on the chief complaint. It is a "concise statement describing the symtom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the encounter." There is also a DG note stating "the medical record should clearly reflect the chief complaint."

So in answer to your question, this makes it clear that the CC cannot be "inferred" but your latter question of where it can be taken from isn't addressed. As long as that "concise statement" is documented somewhere in the record, that should be fine in meeting the CC requirement.

 

[MikeEnos]

While I wouldn't go so far as to say that the Chief Complaint can be inferred from the plan - It can be included in the HPI or Subjective portion of the note. Ideally it will be clearly listed at the top as CC: but if not, you can infer it from the HPI.

CMS Evaluation and Management Services Guide

CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition, diagnosis,
physician recommended return, or other factor that is the reason for the encounter.
DG: The medical record should clearly reflect the chief complaint.
DG: The CC, ROS and PFSH may be listed as separate elements of history, or
they may be included in the description of the history of the present illness.

 

[az2tn@yahoo.com]

Thank you so much for your help